JOINT COMMITTEE ON HEALTH AND CHILDREN debate -
Thursday, 22 Mar 2012

Health Service Issues: Discussion

Chairman

I welcome the Minister for Health, Deputy James Reilly, Mr. Cathal Magee and the officials from the Department of Health and from the HSE. At the risk of embarrassing him, I welcome a fellow Corkman, Barry O'Brien.

I remind members, witnesses and those in the Gallery that all mobile telephones should be switched off. Apologies have been received from Deputy Regina Doherty and Deputy Michael Colreavy who are speaking in the Dáil and from Senator Jillian van Turnhout. There is a vote in the Seanad so some members of the committee are absent for the moment. The business of the committee today is a discussion with the Minister for Health and with Mr. Cathal Magee.

By virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of the evidence they are to give this committee. If a witness is directed by the committee to cease giving evidence in relation to a particular matter and the witness continues to so do, the witness is entitled thereafter only to a qualified privilege in respect of his or her evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and witnesses are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise nor make charges against any person or persons or entity by name or in such a way as to make him, her or it identifiable.

Members are reminded of the long-standing parliamentary practice that they should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable.

Minister for Health (Deputy James Reilly)

I thank the Chairman and members of the joint committee for this opportunity to discuss health service issues. I wish to note the presence of Luke Woods, the third generation of the Woods family to sit in this Chamber.

The first anniversary of the appointment of this Government has just passed and it is timely and necessary to take stock of progress on the implementation of our health reform programme. An earlier edition of this opening contribution of mine contained some typographical errors which I hope have been corrected.

The establishment of a universal health implementation group and a universal primary care group means these will play a central role in the introduction of universal health insurance and they mark important progress in the implementation of our health reform programme. The special delivery unit, which was formed in June 2011 and became operational in September 2011, has cut the number of patients waiting on trolleys in December 2011 by over 30%. During the first two months of this year, the number waiting on trolleys was cut by 17%. I am happy to say that this figure is being maintained this month despite the end of the grace period, to which I will refer later.

There has been an almost 80% drop in people waiting more than 12 months for inpatient treatment in the year ending December 2011. The number of inpatient and day cases rose by 2.5% during 2011. Government approval has been secured for the abolition of the HSE board and its replacement with a new governance structure of directors. Some €15 million has been provided to extend free general practitioner, GP, care to long-term illness patients as part of the road towards free GP care for all. Legislation has been enacted to allow a wider range of registered medical practitioners to provide services under the General Medical Services, GMS, scheme. This presents opportunities to younger doctors who are suitably qualified as GPs and who may be considering going abroad, in that they will be able to stay in Ireland and set up in practice. Indeed, those abroad who wish to return will be invited to do so, given the promising career paths for them in this country providing services to their fellow Irish citizens.

An additional €35 million has been provided for mental health services in 2012 to enhance the multidisciplinary composition of community mental health teams and other key priorities. It is important to mark the work being done by the Minister of State, Deputy Kathleen Lynch, in terms of increasing the community provision of mental health services and moving away from the old hospital-centric model.

The Government approved the extension of the interim risk equalisation, RE, scheme and the introduction of a permanent RE scheme for 2013. A consultative forum on health insurance has been established and has met several times. The market, including any body who is considering entering Ireland, wants certainty. We are providing it. Outside insurers have made expressions of interest, one of which is well advanced.

Two hospital groups have been established around acute hospitals in Limerick and Galway and similar groups will be established throughout the country in 2012. The HSE's national service plan has committed to significant additional spending through the fair deal scheme and a review of the scheme is taking place. The new national adult referral centre for patients with cystic fibrosis at St. Vincent's Hospital is due to open in 2012. This 100-bed unit will also serve patients with many other conditions. The extension of the cervical cancer vaccination programme was introduced in 2011, thus securing protection for young girls against cervical cancer. A draft carer's strategy has been prepared and will be the subject of consultation with carers' representatives.

These are some of the areas of progress, but I would like to make special mention of our drive to move care from hospitals to communities. The Minister of State, Deputy Shortall, and I have done a great deal of work on this issue to ensure that 95% of people's health care requirements can be met as they should be, that is, in the community, where providing that service can be done more efficiently and where availing of the service is more convenient for patients.

The Government has embarked on a major reform programme for the health system, with the clear aim of delivering a single-tier health service supported by universal health insurance that will ensure equal access to care based on need, not income. A critical aspect of the reform of the acute hospital system is the implementation of a new, more efficient funding system for hospital care. Under the money follows the patient funding method, financial incentives will ensure high-quality, lower cost care and will achieve one of our aims, namely, a patient-centred service. If there is no patient, there will be no payment.

We will shortly publish a framework for the development of smaller hospitals. The purpose of the framework is to offer clear information about the future role of our smaller hospitals. It will demonstrate in a practical way that smaller hospitals can and will provide more services for more patients in their local communities. Far from being downgraded or closed, smaller hospitals will be developed over time to provide day surgery, ambulatory care and a range of medical and diagnostic services to the local population. The framework for smaller hospitals will set out the key criteria and principles to which the re-organisation of all hospitals, small and large, must adhere. It is important to state that, while smaller hospitals have lost some services due to safety issues, they are due to inherit more services as we move services and care from larger hospitals to them. We will also move services from smaller hospitals to general practice and from general practice to patients' homes. Improvements in technology allow this last move, in that several conditions can now be monitored at home unlike hitherto. This is an important development, as it enables and empowers patients to look after their own care, which is what they want. Everyone wants as much autonomy over his or her own life and health as possible. This is our aim.

The Government's extensive reform programme will greatly enhance health services. My Department is also in the process of completing the drafting of the health information Bill to provide a legal framework for the introduction of an individual health identifier. This is a key step in patient safety and a component in the development of universal health insurance and primary care registration. The Bill contains key provisions supporting patient safety in terms of open disclosure, adverse event reporting and clinical audit. We are developing a patient safety authority and introducing national standards for better health care. Once adopted, the application of the standards will be reinforced by legislation for the mandatory licensing of public and private health care providers.

Undoubtedly, 2012 and the following years will continue to be challenging. During this period, my Department and the HSE will continue to work closely to maximise resources and efficiency and to maintain services to the greatest degree possible. The economic situation in which we find ourselves has forced us to make decisions that we would rather not have to make. However, it also presents opportunities to examine how we do business, how we can maximise resources and how we can reform the health system to provide the best patient experience possible. The Government has undertaken one of the most challenging reform programmes ever, but this is necessary and achievable. As we reach the end of the first year in government, the positive results achieved to date are there for all to see.

We are succeeding in our attempt to do something that no other Western health service has ever done, that is, improve quality of service with a backdrop of reducing budgets. I thank all of the health service's staff for embracing these changes and for their co-operation in the continued safe delivery of services during the retirement grace period, which has seen 4,515 staff leave since September 2011.

A number of reforms are starting to work, but there will be many more. We will accelerate the rate of reform because, done in the right way and for the right reasons, reform delivers. We intend to continue to deliver.

Mr. Cathal Magee

I thank the committee for its invitation to attend this meeting. I am joined by a number of my colleagues - Ms Laverne McGuinness, national director of integrated services, Dr. Barry White, national director of clinical strategy and programmes, and Mr. Liam Woods, national director of finance. Also in attendance and available to the committee are Dr. Philip Crowley, national director of quality and patient safety, and Mr. Barry O'Brien, who has taken up his new appointment as the national director of human resources, HR.

The committee requested information and replies on a number of specific issues prior to the meeting. It will have received a written response to these issues from the HSE and the Department of Health. My opening remarks will be a brief update on two key matters recently reviewed by the committee.

Regarding medical cards, when the committee visited the Primary Care Reimbursement Service, PCRS, in Finglas on 2 March, it was advised that a backlog of applications had developed in 2011. A comprehensive action plan has been developed and put in place to deal with this issue. On 26 January 2012, the backlog stood at 57,962, which was reduced to 31,456 by 2 March. Figures for 14 March show the backlog has been reduced to 20,967. The PCRS is on track to clear the backlog, as planned, by end of April. Under the plan, a medical card will remain valid, irrespective of the expiry date shown on the card, once the holder is genuinely engaging with the HSE review process. Eligibility for services can be confirmed by any doctor or pharmacist or by the medical card holder online through the GP practice system, in any local health office or through the helpline.

A range of initiatives has also been implemented under the plan in order to address many of the issues which have arisen in the context of the initial months of centralisation. A key change has been the introduction of self-assessment reviews for card holders under 70 years of age. In addition, card expiry dates have been extended from two to three years in most cases. A further development is the provision of system facilities to GPs to allow the temporary extension of card eligibility for expired cards and to add new babies to existing cards. In cases where a medical card is required in emergency circumstances, such as for a terminal illness or in respect of a serious medical issue, an emergency medical card may be issued. Such an application can be initiated through the local health office. Details of this procedure are available to all GPs and social workers. Such cards will be issued within 24 hours. As previously, no means test applies to an application by a terminally-ill patient and all terminally-ill patients will be provided with medical card numbers for a period of six months once their medical condition is verified by a GP or a consultant.

In other emergency cases - for example, where a person in need of urgent medical attention cannot afford to pay for it, etc. - the HSE issues all emergency medical cards on the presumption that the patient is eligible for the card. This means that the patient satisfies the eligibility criteria in terms of a means test or on the basis of undue hardship and that he or she must follow up with a full application within a number of weeks of receiving the emergency medical card. As result, emergency medical cards are issued to named individuals and the eligibility period relating to them is six months.

The HSE has also commenced a review of medical card operations with support from PwC, to develop medium and longer-term improvements. The report and implementation plan will be completed shortly and it will be forwarded to the joint committee when it is available. The joint committee has scheduled a special meeting for 24 May next in order to review progress on the medical cards issue. I expect that the report to which I refer will be considered in detail at that meeting.

As of 9 March last, the total number of staff members who retired under the "grace period" retirement scheme was 4,515. I have set out in the documentation provided to members the breakdown of the staff categories involved in this regard. Planning to manage the impact of the grace period has been ongoing at national, regional and local levels. The overarching aim in this process has been to protect critical front line essential services. A range of national measures designed to reduce the impact of retirements on front-line services are in place. These include using the provisions of the public service agreement - also known as the Croke Park agreement - and delivering greater productivity through the implementation of the national clinical programmes. Where critical gaps in services cannot be filled through redeployment, reconfiguration or the reorganisation of services, €16 million has been allocated for targeted recruitment and for filling critical roles aimed at minimising the impact of early retirements on front-line services. Some 288 of these replacements will be in the acute hospital services and a further 244 in community services. The figure for community service replacements does not include the additional investment and posts - some 414 - identified in the HSE's 2012 national service plan for mental health and the investment of €20 million in respect of replacement posts in the area of primary care.

The regional directors of operations, hospital CEOs and area managers have provided written assurances to the effect that the risks associated with the grace period retirements have been identified and that the appropriate measures to minimise impact on front line services are being managed appropriately. The regional and service level contingency plans continue to be monitored as part of the transition process. I wish to echo what the Minister said in the context of thanking staff for what is unprecedented co-operation at an operational and front line level in respect of the changes and requirements involved in dealing with the significant staff reductions which have occurred.

Chairman

I thank Mr. Magee for his opening statement. I join him and the Minister in thanking the staff who work in our health service and in complimenting them on the level of commitment they display each day. Before I call on Deputy Kelleher, I wish to ask one question. In the context of what Mr. Magee said with regard to the medical card processing update, a commitment was given to us at our meeting in Finglas that the relevant information would be posted on the HSE's website. Has this been done? I was not able to find the information when I visited the website. I accept, however, that this might be due more to my IT skills than anything else.

Ms Laverne McGuinness

No. The information is to be posted on the website. We were waiting until after our appearance at this meeting before proceeding to post it.

Chairman

That is very good. I remind members that the initial three speakers will have five minutes each in which to contribute.

Deputy Billy Kelleher

Is that in the context of the questions we tabled or does it relate to the broader-----

Chairman

As the main Opposition spokesperson, Deputy Kelleher has five minutes for his opening contribution. To clarify, members who have submitted questions will be allowed to ask a supplementary question based on those initial questions. There are 40 questions before the committee and a vote is due to take place in the Dáil at 12.50 p.m. I do not wish to curb people's contributions but I will intervene in the interests of fairness. If the three main spokespersons can limit both their comments and the questions they wish to pose, this will allow most others present to contribute.

Deputy Billy Kelleher

I thank the Chairman for clarifying the position and I welcome the Minister, Mr. Magee and the other officials from the HSE. As well as making comments, I will also go through the questions I have tabled in order to save time.

My first point is directed to the HSE. On medical cards, there appears to have been a breakdown in communications with regard to the changes that were made in respect of the extension of expiry dates from two years to three and situations where cards that are out of date will be considered valid in circumstances where the holders are engaging with the HSE. Pharmacists continue to contact Members of the Oireachtas stating that people's medical cards are out of date and inquiring as to whether they will be honoured. Is the necessary information in this regard flowing freely to GPs, pharmacists, staff of the HSE and members of the general public? This is not a criticism but there appears to be an amount of confusion in respect of this matter. I am aware that the staff in Finglas are operating in a stressful environment - I regret the fact that I was not in a position to visit the facility with other members - and that they are making every effort to assist people. We acknowledge the efforts that are being made and the improvements that are being brought about.

It was obvious last year that there were huge difficulties at the office in Finglas in the context of the processing of medical cards. Why did it take so long for what were fairly obvious decisions to be made in respect of the assessments relating to applications for medical cards by those who are terminally ill or who have long-term illnesses? Many Deputies raised this matter in the House and elsewhere. Why was there a need to reassess these people's applications, particularly as it was highly unlikely that their financial circumstances would have changed? With the backlog that built up in this regard, new applicants were unable to secure their medical cards. When Deputies or Senators raise matters of this nature in the Houses, they are normally not figments of their imagination. In such circumstances, Members of the Dáil and Seanad are reflecting the genuine concerns raised with them by members of the public. Perhaps a more prompt response in the context of dealing with medical cards for the terminally ill and those with long-term illnesses would have been of assistance in ensuring that the applications of new entrants to the scheme were dealt with in a more expedient fashion.

Mr. Magee referred to flexibility in the context of the Croke Park agreement. Is there good flexibility for the HSE under the various headings of that agreement? What is the position, for example, with regard to medical card applications and renewals? Is there a free movement of staff into areas where blockages have occurred or is there more work to be done in this regard?

On corporate governance, the establishment of hospital trusts or groupings of hospitals and the framework for smaller hospitals, will primary legislation be required in respect of the establishment of the trusts? Will the forthcoming Bill to deal with the changes to the governance of the HSE also deal with this matter or will further legislation be required in order to facilitate the establishment of not-for-profit hospital trusts? There is a seismic shift taking place in the context of how health services are delivered. In that regard, I am concerned by the fact that there is no debate taking place in this regard. Members can discuss this matter in broad terms but it is difficult for us to get down to the nitty-gritty of what will constitute a hospital trust. Will, for example, such trusts be configured on the basis of the Hanly report? Will a new report be commissioned in order to ensure that duplication does not take place? We must also ask whether the proposal in this regard will, in fact, proceed. I am sure there is quite an amount of resistance to it and there will be those who believe that it is not necessarily the way to proceed.

Will the framework for smaller hospitals be published in advance in order to ensure that when the hospital trusts and hospital groupings are being established, there will be a co-ordinated response in the context of the delivery of services in particular regions? Will that framework be published in advance to ensure that when these hospital trusts and groupings are established we will have a co-ordinated response to the delivery of services in a region? I presume trusts will be in place in various geographical areas such that there will be a main centre of excellence with supporting smaller hospitals geographically located around it but that there will still be a centralised system to ensure the delivery of specialist services in the various areas as opposed to a downgrading in some areas and an oversupply in other areas of various specialties and treatments. There is probably a need for a broad debate on this issue not only in terms of the reconfiguration of the HSE but on the delivery of services through the establishment of hospital trusts. I would have a view on whether the hospital trusts will deliver what Minister says they will and whether they may be an encouragement for hospitals to provide less expensive treatments as opposed to the expensive ones in view of the budgetary constraints there will be on them. What mechanism will be centrally focused to ensure hospitals are obliged to deliver specialist treatments in various geographical regions?

I wish to raise the broader issue of the universal health insurance, a key policy platform of the Government. I raise this issue often because I am not sure at what stage it is. I am aware the Minister established an implementation group but I am not sure as to its terms of reference. Has a decision been made that we will have a universal health insurance model and, if so, is it to be based on the Dutch model, the German model or an amalgam of various models or best practice throughout the world? What are the implementation body's riding instructions and terms of reference? If it reports that a universal health insurance model may not be eminently suitable to this country, what will the position be then? Has it been told to find the best system that suits this country or can it report that universal health insurance is not the ideal method of funding our health services in the future? That is a key issue we need to debate. While we wait for the implementation body to report, it is important to have a broad discussion on that.

With regard to governance, oversight and responsibilities, the special delivery unit is at the heart of the delivery of health care, in terms of oversight of hospitals, hospital management and in implementing policies at a regional basis to address blockages in accident and emergency departments in acute hospitals and movement into long-term residential care. Will it be part and parcel of the reconfiguration for hospital trusts and grouping of hospitals and what is its central role in the decision making process? We have the Department of Health, with the Minister as the political head, the HSE and the special delivery unit. With all these various groupings working in tandem but not necessarily in concert, I am concerned that frictions could evolve. Who is ultimately responsible? Is it the CEO of the HSE, the Minister, or who is fundamentally responsible for the delivery of the budget voted through for the HSE every year? Where does the guillotine fall in terms of responsibility for the implementation of the Vote allocated to the HSE every year? I am not sure about that and I believe other people are not sure about it either in view of replies I get to parliamentary questions. That is not a criticism of anyone because I understand and accept that the Minister is bringing about a transformation of the health services. I could argue forever more whether that is a positive transformation but only time will tell whether it will be a success or whether it can be implemented. Those are the key issues I wanted to raise.

Deputy Caoimhghín Ó Caoláin

I welcome the Minister, the CEO of the HSE and their colleagues. The medical card processing progress is noted and acknowledged. It is fair to acknowledge when progress is being made; however, there remain issues to be addressed with the Finglas operation and we will have the opportunity to address those further in May when Mr. Burke comes before the committee.

On the departure of in excess of 4,500 employees from the HSE, the recruitment embargo that is ongoing and the further redundancies targeted in service plans across the four HSE areas during the course of 2012 will add additional pressure on a health delivery system that is already under intense pressure. The additional departures, deemed as required by service plan authors, will worsen the current situation. I do not believe that the CEO's targeted recruitment is the answer to all of this; it is barely a stopgap. We need to seriously examine the issue of the recruitment embargo and I urge the Minister to do so.

I want to express particular concern about care for older people. We are threatened with the closure of nearly 600 additional residential beds and entire care homes, the number of which is as yet unknown. What is happening could be described as a pincer movement, as this is being done at the same time as care in the community is being reduced with reduction in home help hours. Public health nurses, with whom I have engaged, and other voices point to a deterioration in the level of care and supports and increased vulnerability because there is not now the opportunity to maintain surveillance of vulnerable older people through regularly keeping in touch and keeping an eye on them. Home visits are becoming few and far between. It is an important and serious area. It is all very well having improved quality standards but we will not have the care in this respect to translate it into service delivery and that will mean we will be in real trouble.

Regarding the Rare Disease Day on 29 February, I commend the Chairman and members of the committee on having a special sitting in regard to same. Having gone over the detail of the contributions of the various representative groups, there is a clear, common position. It is vital to guard against the isolation people coping and catering for rare diseases can find themselves in. Many of these are in very small numbers. Some form of funding or logistical support needs to be made available. I ask the Minister or the CEO of the HSE whether there is any prospect of one or two officials in either the Department or the HSE being assigned to offer practical and logistical support. When I think of the situation in regard to Rett Syndrome and 1p36 deletion syndrome, parents are swimming against the tide. It is very difficult for them given that it is difficult enough to cope and contend with the problems presenting with their young children. The system is not as supportive as it could be. I would like to make that special appeal.

I note from a reply to a question I raised regarding the Dublin north-east regional plan and acute hospitals that the Minister speaks of the development of the role of smaller hospitals and he made that point again here in his contribution, yet this is against the backdrop - as set out in the presentation of all the material for this meeting to members - of a report on a feasibility study carried out regarding a medical assessment unit at Monaghan General Hospital. I ask if the CEO can offer any further comment. This is a majority report. There was objection from the eight members who were appointed to carry out the assessment. It is the view not only of the objecting voice within the group but it is acknowledged within the report that the time constraints were too restrictive in terms of carrying out the detailed assessment that was necessary. This is confirmed in the wording of the report. It states that to provide the necessary structures in staffing would entail a significant cost, but how was the cost assessed? The report admits that costs could not be clearly defined as the size and scope of the proposed unit were not agreed, yet the terms of reference state clearly a detailed analysis of the pay and non-pay costs must be provided. That contribution surely stands up and confirms the objections of Dr. Illona Duffy, one of the members of the eight-person panel. It is not good enough that this report is then accepted and that is the end of the matter. The Minister was very warm in his reaction to the proposal in the middle of 2011. I appeal to him not to make this report the end of the matter. The Minister should recognise the objection of the member to whom I referred and the flaws agreed and accepted by the other seven members and look at the issue again in the light of his stated support for developing the role of smaller hospitals.

Deputy Denis Naughten

I thank the witnesses for attending and for their presentations. I will turn to the Minister first and his contribution on the framework for the development of smaller hospitals. Could he give a more definite time line on that particular report? "Shortly" can be a very long time. When will the Department publish the mortality report on acute hospitals? It was to be published shortly after July 2011 but we are still waiting for it. As the Minister is aware, reputational damage is wrongly being done to Roscommon County Hospital because the report has not been published. When will it be published?

We were to have a report at the end of January on the air ambulance service but no report was published. My understanding now is that the air ambulance service is to be based at Custume Barracks in Athlone and that it will be operational by mid-May. Could that be clarified and will it form part of a network with the Coast Guard in conjunction with the Air Corps to provide a service throughout the country?

On non-consultant hospital doctor, NCHD, recruitment, we have been given commitments by the Department of Health and the HSE that we would recruit NCHDs on a group basis. We now have a group hospital network in the west comprising Galway and Roscommon University Hospitals yet each of the hospitals is recruiting individually for NCHDs through the central office of the HSE. If this was such an issue last July and we were given commitments that we would have a co-ordinated recruitment process, why are we still in the same situation coming up to next July whereby junior doctors are being recruited individually by smaller hospitals, which puts further pressure on the operation of such hospitals?

I thank Mr. Magee for his acknowledgement of the issue on medical cards. Based on the figures from last week, we still have 781 applications waiting for six months or more to be processed and 1,838 applications waiting for seven months to be processed. One in eight of the applications currently in the backlog is waiting for at least seven months to be processed. Is that good enough? It is not good enough to tell people who are waiting for up to eight months for an application to be processed that their application will be processed by the end of April. In many cases those same people have submitted documentation on more than one occasion to the primary care reimbursement service, PCRS, yet they are being told that their application is not being processed because they have not responded to the queries. I would welcome an answer from Mr. Magee in that regard.

I wish to turn to question No. 7 that I tabled on the reconfiguration of disability services. Currently, the HSE is informing service providers that it has no money to provide new, additional day care services from 1 September 2012. That will cause a crisis for young people who reach their 18th birthday this year who expect and hope to avail of a service next September that will not now be in place. My question is for both the Department and Mr. Magee. Relatively recently we introduced legislation, rightly so, to make the HSE legally responsible for the after care of children following their 18th birthday who were in the care of the HSE, yet we are denying a service to people with an intellectual disability from 1 September next. What will be done to address the issue? In that context, the Department is producing a value for money and policy review, which could go a long way towards reforming the system. What stage is the report at and when will it be published?

Question No. 8 relates to the reconfiguration of services for older people. When does Mr. Magee hope to publish the report on bed reductions across the country? The response indicated that community-based services would be developed in terms of home help, home care packages and meals-on-wheels. In my primary, community and continuing care, PCCC, area - I am sure it is the same across the country - home help hours and home care packages are being reduced and meals-on-wheels are being withdrawn. How can we have a national policy that says one thing yet the implementation is something different?

Deputy James Reilly

I thank the members for their questions. Deputy Kelleher asked about the GMS. I will leave it to Ms McGuinness to respond to that question. He also asked about legislation on hospital trusts. Hospital trusts will come later and require legislation but nothing that has been proposed in the immediate legislation on directorates will in any way inhibit that happening. What will happen in the interim is that groups can be established; shadow groups of hospitals can be put together. Much discussion and consultation around that is currently taking place. However, when the legislation is produced, there will be plenty of opportunity for debate on the formation of the new hospital directorate as well as the primary care directorate and the mental health directorate, among others.

Deputy Kelleher inquired about the system that will apply to universal health insurance. The group has been asked to examine all aspects of universal health insurance and to come back with a White Paper in October. I have the grouping with me for information but I do not wish to give a long list of names, other than to say that the list contains a comprehensive group of individuals. It comprises a mix of those with executive responsibilities within the health service and external expertise, including international experts. In line with the pragmatic focus of the group, its membership will be flexible and subject to periodic review as different stages in the implementation process are reached.

Deputy Kelleher also expressed his concern about what I will paraphrase as people tripping up over each other in terms of the numbers involved in the new structures that have been put in place. Nothing could be further from the truth. There is cohesion now between those in the special delivery unit in the Department, the clinical programmes which will come into the Department and the front line.

Chairman

I apologise for interrupting the Minister but I must inform Seanad Members that there is a vote in the Seanad.

Deputy James Reilly

The example I want to give is the manner in which we successfully managed to reduce the number of people lying on trolleys at 8 a.m. As I said previously, we are now going to move to a more challenging situation where we want all those who arrive in an emergency department to be dealt with within nine hours from the point of registration to when they either leave to go home or go to a bed within the hospital. For 95% of people the timespan should be six hours. Equally, we want to reduce the inpatient waiting time from a maximum of 12 months to nine months. That is a challenge, in particular when one considers, first, the moratorium on staff; second, the grace period with in excess of 4,000 people having left the system and third, a reducing budget. Yet, staff on the front line are engaged with the SDU and management to achieve that.

This morning I announced a new development - a new diploma in leadership and quality - for managers, GPs, consultants and nurse leaders so that all of our clinical leaders and all those involved in management will have the skill-sets to do the job. In the past I have been critical, as have others, and acknowledged that we have had a problem with the management of our health service in that many excellent people were promoted out of administration into management but were never given the skill-set to do the job. That will be corrected. A sum of money will be put aside annually for the next number of years to ensure that everybody who ends up in a managerial or clinical leadership role will have gone through this course, got this diploma and have the skill-set to do the job. I remind members that Dr. Susan O'Reilly from the cancer service has made it clear that we get a 10% increase in improved outcomes in mortality through better organisation and management. If it applies in cancer care it applies across every area.

Mention was made of the Vote and who was in charge of the health service. The bottom line is that Vote 39 is the Health Service Executive, and Mr. Magee is to my left, and Vote 30 is the Department of Health, and the Assistant Secretary in charge of finance is to my right. I said before I was re-elected, before this Government came to power and before I was appointed Minister for Health that we would take responsibility for the health service much more so than was the case in the past. I have done that and will continue to do that. I am happy to be charged with that and if a problem arises I consider it to be my problem. I will not be at arm's length as a Minister. I will be fully engaged.

Deputy Ó Caoláin mentioned the embargo and concerns about its effect. I put it to the Deputy that he engaged in considerable shroud waving before the grace period ended and talked about all the things that would happen which, thankfully, have not happened because of the great effort of the staff. Creating anxiety among service users such as pregnant mothers and cancer sufferers is unnecessary. We should all strive to support our health care staff in doing the difficult job they do.

Deputy Caoimhghín Ó Caoláin

And they do, and I resent-----

Chairman

The Minister, without interruption please.

Deputy Caoimhghín Ó Caoláin

-----the tone of the Minister's accusation.

Deputy James Reilly

I did not interrupt the Deputy.

Deputy Caoimhghín Ó Caoláin

The Minister should answer the question.

Deputy James Reilly

I did not interrupt the Deputy, and I resented the slight he put upon the health service and the risk to people's-----

Deputy Caoimhghín Ó Caoláin

It was not-----

Chairman

The Deputy had his chance. Allow the Minister to reply.

Deputy James Reilly

We should put that to one side and in future remember that when we are bringing in changes which present challenges we should support those who must meet the challenge rather than do otherwise.

Deputy Caoimhghín Ó Caoláin

The Minister's dynamic contingency plan.

Deputy James Reilly

We must support the staff and the excellent job they are doing and encourage them to continue to embrace change because if we continue to do things the way we have always done them we will end up with the same results, and we do not want that. We want to see more patients treated more quickly.

On the issue of rare diseases, it is a good idea to have a contact in place to which people can relate. I am aware that progress has been made and that a new clinical care programme has been put in place to deal with rare diseases, and that is being developed further.

The report is to hand on the Monaghan medical assessment unit. It has been accepted by the regional service but I agree that is not the end of the matter in that it has been referred to the acute medicine programme for its view.

Deputy Naughten asked about the timeline for the small hospital framework document, the mortality report, the air ambulance and a co-ordinated response in terms of manpower. The timeline for the small hospital framework document is that it is to go to consultation in the next couple of weeks. I believe the timeline for the mortality report is next month. The air ambulance is an issue Deputy Frank Feighan has been pursuing, along with myself, for some time and it is something we will deliver very shortly. It will be a safe service.

Deputy Billy Kelleher

That is very welcome.

Chairman

The Minister, without interruption please.

Deputy James Reilly

It will be the first helicopter emergency service in the country and will be launched in the next number of weeks.

The manpower issue will be dealt with best by the Deputy's friend and mine, Mr. Barry O'Brien, who is the new human resources director.

On the reconfiguration, I will refer that question to Ms McGuinness as well. It is from the HSE. The disability services issue will be dealt with also by Ms McGuinness.

Deputy Denis Naughten

The Department report on disability services.

Deputy James Reilly

Yes, the value for money review will be dealt with by Ms McGuinness.

Ms Laverne McGuinness

I will deal with the questions from Deputies Kelleher and Naughten on medical cards simultaneously. We acknowledge that there have been difficulties with the medical cards. The members of the joint committee visited PCOS in Finglas earlier this month. We have put together a short-term action plan to address the backlog immediately. That will be forwarded to the committee in the next 12 days but many of the actions have been done. We have also examined what is needed in the medium and longer term to ensure we have an appropriate service that does not see the delays that have built up in the past and that we have appropriate communications channels.

An issue raised was about communications and whether the general practitioners, GPs, and the pharmacists have been notified of the changes. A communications plan is being drawn up as part of the action plan. We will have the backlogs cleared before the end of April and the communications plan will also be launched before the end of April to ensure we have much more information on it. We have been in contact with the GPs. They are aware of the changes that have come into effect. We met with the Irish Medical Organisation also and it is aware of the changes that have come into effect. We will launch our performance targets and how we are tracking and monitoring them on the web in the coming days as well. All of that will be set out and forwarded to the committee. In terms of the more medium and long-term plan on which we got a small amount of assistance from PwC, we will forward that to both the joint committee and the Committee of Public Accounts at the same time.

There is an issue with regard to customer services and what is needed to link up the local office with the call centre and the TDs to ensure that when somebody calls a full breadth of information is available to determine the problems and that they can access all the information.

Deputy Naughten raised the issue of forms being lost and people being asked to resubmit them two or three times. There is an issue in terms of the filing because of the volume of paper being sought. We are looking at changing the application form and reviewing the guidelines to ensure we do not need the same level of information submitted. Members will see that is set out clearly in the action plan.

In the more medium term we need to examine a file management system but it will be a number of months before we can get a document scanning system in place and in operation.

Chairman

Is the form being changed? In terms of Mr. Magee's questioning regarding PwC has any consideration been given to bringing in a focus group of patients or medical card users who would inform the HSE much better than paying an inordinate amount of money to PwC, which will tell it at first hand the limitations it is encountering? I welcome Ms McGuinness's comments regarding the change in the form about which we had a conversation. We must move away from essay type questions to a simple "Yes" or "No" answer because the process must be patient driven or, in the HSE's case, customer driven.

Ms Laverne McGuinness

The Chairman's point is valid. PwC is not changing the application form. We sent it off to the National Adult Literacy Agency, NALA, for its input. PwC would not have that level of detail or information. We have got input from service users in terms of what must go into that form. The form will not be revised and ready until 30 June. The Chairman will see that date set out in the action plan. PwC would not be able to do that piece of work with us. It is a much more user friendly service. The same applies to the on-line form. While we have our application form on-line a great deal of paper documentation is still being requested which almost defeats the purpose. We are addressing all of those issues one by one in the action plan but as of now we want to focus on the people who have been delayed inordinately. We want to focus on getting medical cards to those who are entitled to them as soon as possible. There were 57,000 applications outstanding on 26 January. That reduced to 20,967 on 14 March and as of today the figure is 14,853. We will clear that backlog. Where people send in forms two or three times, they are contacted. If the documentation sought is not necessary, we do not ask that it be submitted again. The people in question are telephoned and a dedicated team has been set up to address the issue. We will have both reports available.

PwC was asked to do a nominal piece of work on what we were missing. Bearing the public accounts in mind, a huge sum of money was not spent on this work.

Chairman

Considering the statistics for people waiting a long time, can we take it that we will not see a recurrence of the inordinate delays, perhaps from the end of this year?

Ms Laverne McGuinness

Yes. It is not just a matter of addressing the backlog because we need to find out what happened in the first instance. One of the key points is that renewals of medical cards were being considered in the same way as applications for new medical cards. The same documentation was being sought and this caused a big hump in the system. Applications for renewals can now be self-assessed and the documentation is not sought. This immediately removes the hump. Medical cards now last for three years rather than two.

The PCRS has been in operation for six months. We said we would review centralisation at the end of six months. That is what we started to do in January. It is unfortunate that there have been delays affecting people who need medical cards. The emergency service is working for people who are terminally ill and those with significant medical issues who have a consultant's note. These cases are also being considered through the local offices.

Mr. Cathal Magee

The medical card issue is probably a good example of where there can be too much ambition in a change programme, or of taking on too much. There were probably three strands to the programme, one of which was centralisation which in itself is always challenging as a process. Second, there was a more active renewal process. Owing to the growth in the number of eligible medical card holders, there was a significant requirement for a more active and dynamic renewal process. The number of medical cards has increased by 52% since 1 January 2005. The number has increased from 1.1 million to over 1.7 million. Therefore, there has been a massive increase in eligibility, which reflects economic circumstances. The third objective was to effect standardisation owing to the move from one set of practices and protocols across many centres to a different one.

Addressing the three strands at the one time proved too much. The work under way with the action plan and team will afford an opportunity to put in place a service offering best practice and an administrative centre to support the population of medical card holders. Some of the policy changes made to renewal periods and the electronic enablement of cards locally through general practitioners are such that we will see significant benefits accruing from a more standardised approach for the whole population. At the May meeting the HSE will be better able to outline exactly the progress made. There has been significant progress made to date.

Communication is the key. That is why in my opening remarks I raised some of the associated issues. We need to be more proactive in making sure people understand exactly the new arrangements. There is work to be done in that regard in order that general practitioners, pharmacists and the public will understand the new arrangements in place to deal with medical card application processing.

Deputy Ó Caoláin referred to manpower, the embargo and recruitment. In this regard, money presents the fundamental challenge. As the Deputy knows, under the current service plan, there are very significant reductions in funding. This year, even under the existing service plan, there will be a significant challenge to try to deliver the services scoped in the plan with the envelope of money available. There are pressure points in some of the major acute hospital systems and there is considerable dependency on income in the plan. We have significant aggressive targets in seeking a reduction in drug costs. There is an increased number applying under the retirement grace period arrangement which will result in additional funding costs, perhaps up to €60 million, for lump sums.

Considering our service plan and the financial outlook, this will be an extremely challenging year in which to deal with the financial pressures. That is the underlying issue. It is a funding rather than a manpower issue. At previous meetings I outlined that the HSE was well within its targeted control framework numbers. There is significant recruitment taking place this year, bearing in mind the recruitment of over 530 staff with a view to replacement, for a which a figure of €60 million has been budgeted. Some 414 posts come into play in the mental health service and there is a €20 million budget in the primary care sector. The overall number recruited in these three areas will be up to 1,200. This, however, does not deal with the number who have left. The real balancing issue is the provision of funds, as we recognise the funding is not in place.

Deputy Caoimhghín Ó Caoláin

Will Mr. Magee address my question on older people, to which the Minister did not respond?

Mr. Cathal Magee

There is no doubt that under the service plan, there will be a reduction in services in the community and the acute system. However, the work being done under the local service plans is trying to give priority to services. Home care packages have not been reduced. It is a question of ensuring the discharge of elderly people from the acute system is handled in a much more staged way through the provision of intermediate and transitional care, in addition to long-stay residential or home care. There is a lot of work being done in this regard through the clinical programmes and the review of the way in which the fair deal scheme operates. The financial pressures on the system are dictating resource availability, both in terms of people and cost. This is unlikely to change.

I will ask Dr. White to comment on rare diseases and the medical assessment unit's report.

Dr. Barry White

There are people who are vulnerable owing to rare diseases and we need to improve the available services for them. Some of the improvements may have cost implications and some, as mentioned by the Deputy, may carry a very small additional cost. In the medium term we are trying to target the issues that will not have a major financial impact.

There is a programme which is working very well in the area of haemophilia, especially in terms of patient involvement in the planning and delivery of services. There are probably lessons we will learn in this regard in determining what we need to do about rare diseases. We have already started work to effect improvements. Some rare diseases affect many, while others affect only one person. Both present slightly different challenges. Where there are small but relatively significant numbers, we need to build services for the affected patients. Where there are only one or two patients with a certain rare disease, it poses a challenge, even in terms of how we embed national expertise and link with other centres internationally. We will be happy to revert to the committee on the issue.

Chairman

We had a very positive meeting on 29 February and many good recommendations were made. We had a meeting with our colleagues in the Northern Ireland Assembly on the issue. We hope that, as a consequence of our having done so, there will be a linking up between North and South. We would be very happy if the delegates reverted to us in this regard.

Dr. Barry White

We will be happy to do so. We agree with the Chairman.

Deputy Caoimhghín Ó Caoláin

What about the medical assessment unit?

Dr. Barry White

There has been a report produced and we will review the matter. We want to see volume and services through the hospital in question. It is a question of what can be provided there. The report mentions a rapid access service and we would like to explore how it can be delivered. We will revert to the Deputy personally or through this group.

Ms Laverne McGuinness

There were two further questions on the reconfiguration of disability services and day places, particularly for children who will finish this year and come out at 18 years of age. In the case of the latter, traditionally there has been funding to provide day services and day places for children finishing school. However, we did not get it this year as money is not available. We have met a large group of disability providers which understand the budget is what they have available. We have asked them to look at other areas within their broader sectors to ascertain where they can generate efficiencies in terms of staffing ratios, back office functions and so on. We met them as a group and they must now come back with their plans, in which they must look internally to ascertain where they can generate savings to provide such care.

A significant range of reconfiguration programmes are under way in disability services. A number of reports have been published that will assist in achieving greater efficiencies. I refer to congregated settings which take people from institutionalised care into the community, as well as supports for people with disabilities such as host families in the community rather than institutionalised respite care, all of which have economic benefits that we hope will be delivered back to create the extra flexibility and funding for day services required.

The Department is working on the value for money report which it is understood will be available later in the summer or the autumn. However, the agencies are aware of much of the work that has been undertaken in this regard and are working through where such efficiencies can be generated.

Chairman

I apologise to Deputy Denis Naughten but a vote has been called in the Dáil. I propose that the sitting be suspended until after its conclusion.

Deputy Denis Naughten

Briefly, will Ms McGuinness confirm that people will, at least, know by the summer whether a place will be available next autumn? There is great fear among parents.

Ms Laverne McGuinness

I will have to revert to the Deputy on that point. Each agency must ascertain what its budget is and what is available to it.

Chairman

I apologise to the delegation for being obliged to suspend the sitting.

Sitting suspended at 12.55 p.m. and resumed at 1.35 p.m.

Senator Colm Burke

My colleagues have mentioned the issue of rare diseases on which we had a constructive debate in the Seanad for two hours last week in which very good contributions were made.

I welcome the replies to questions Nos. 9 to 11, inclusive. It is also welcome that structures have been put in place for junior doctors, including for monitoring where interns will be deployed. I note, however, that with the monitoring process in place, some 43% are left in the system. I also note that a steering group has been established and that recommendations have been made, although we have not yet received details of them. Are these recommendations being implemented? Is it foreseen that within two or three years, instead of 43% remaining on to work in Irish hospitals, the figure will have increased?

My second question concerns the Irish Medical Council. It may not be possible for the delegates to answer it, but I am concerned about it nonetheless. It concerns two Irish graduates who worked in Irish hospitals and then went abroad for two or three years. They came back last December to work here. However, two months after applying to the Irish Medical Council for registration, they found that their registration had still not been completed. That is very unhelpful from the viewpoint of those who want to return to work in the Irish health system. The two people concerned are Irish graduates who have worked in Irish hospitals. One of them went to New Zealand and within one week of applying had received clearance to work there, yet on his return home he found that eight weeks on he still had not been registered by the Irish Medical Council. I wonder if the process could be tidied up. It is certainly unhelpful from the perspective of trying to attract junior doctors back into the Irish health system.

I welcome the comprehensive replies I have received to my questions. In addition, it is welcome that a new system has been put in place for the recruitment of junior doctors. This is a good development, compared to the system that was in place last year.

Chairman

I wish to add to Senator Colm Burke's question. Has anything been done in the intervening 12 months to ensure there is a career path for junior doctors? Part of the problem we have encountered is that young doctors tell us there is no clear career path for them.

I apologise to the delegation for the inordinate delay which was caused by a number of votes being taken together.

Deputy Catherine Byrne

When I was in opposition, I referred to the then Minister for Health holding a poisoned chalice. I still refer to it as such, but the current Minister has grasped it with both hands and is making progress.

A few issues arise from what the Minister and the CEO have said. I welcome the introduction of a six month period for medical card holders, particularly for those whose medical cards are being examined. I agree with other speakers that this is not well known because GPs and pharmacists have contacted me about medical cards being in transit somewhere. If it could be made more definite in the public eye, it might help.

I thank the Minister for announcing that there will be a review of the fair deal scheme, but I would like to know, if possible, what the review will entail. What will be reviewed?

Questions Nos. 3, 23 and 24 are in my name. Question No. 3 concerns the nursing home scheme. I have raised this issue, in particular, because many people with elderly relatives in long-term hospital care settings have told me they are being put under extreme pressure to take them home. In that context, I refer to the importance of the community care package, although I am finding it difficult to obtain any information on it. In particular, I refer to dealing with families who may be able to bring home their elderly family who are ill but who cannot because it seems really difficult to get into this intermediate care package. I wonder whether there will be an additional budget to extend it.

I agree with other contributors on the cuts in home help services, but I am not sure that such services can be supported any more if they only provide a cup of tea and the sweeping of a floor. They must be more comprehensive.

On primary care, particularly the new primary care health centres in Inchicore and Ballyfermot, the former of which is open and the latter of which, hopefully, will be opened within the next three weeks, I bring to the attention of the Minister and the rest of the staff, and particularly to the CEO, that last year, and even before that, I would have been able to ring the local health centre to raise a query with the district nurse about somebody or to ask her to call out. There was a serious incident, on which I contacted the new primary health care centre in Inchicore and in respect of which I was treated in a disturbing manner on the telephone by the front line service person. I was told that staff had been directed by management in the HSE not to deal with queries from public representatives anymore. I found that quite disturbing because all I really wanted was to ask was whether the district nurse would call in on somebody who had an injury on which she might be able to advise, not about the case specifics. I was shocked to hear that the manager of the centre sent a letter in November last to the staff stating that because of the moratorium they were not to deal anymore with public representatives' queries. As I stated, I was not asking a specific question. It just related to an elderly person who had injured himself and I was looking for the district nurse to call in on him.

I welcome the opening of the centre, which is a beautiful place, and also the one in Ballyfermot. I want to bring to the attention of the CEO and the HSE that I was at a public meeting last night in Ballyfermot about the closure of the old health centre, which, I was told yesterday, will be sold through the HSE. People are concerned about to whom it will be sold and what will happen to it over the months when it is left unsecure, and I hope that something can be established on that. Councillor Vincent Jackson and I stated that we would contact members of the HSE to discuss the matter.

I want to raise questions No. 23 and No. 24. Question No. 23 was on the closure of St. Brigid's nursing home in Crooksling. I only want to know how long more will the consultation process take and how long more will it be before a decision is made on Crooksling because it will impact on people, not only those being nursed there but in other areas as well. When will the consultation process end?

On question No. 24, I want ask about the school-age team. My question was specifically about the closure of Brú Chaoimhín in Cork Street and the funding that had gone into refurbishing the building to bring in some of the services that were in rented accommodation elsewhere, particularly in Emmet House in Thomas Street. The following question is on the school-age team based now within Brú Chaoimhín. How can we find out how this group works? Would it be possible to ask that the committee meet this school-age team to see how it intervenes with children who are in difficult situations in the classroom for early intervention? I have had need over the past couple of years to try to deal with the team and it can take up to six or 12 months to have it even look at somebody in the environment of his or her school.

On the last one, what is the role of these 60 staff of the Eastern Vocational Enterprise, EVE, centre which is being moved into unit in Brú Chaoimhín and what number of trainees are involved?

Deputy Charlie McConalogue

I want to refer to three questions which I submitted.

Chairman

I will list the numbers. These are questions Nos. 34 to 36, inclusive.

Deputy Charlie McConalogue

They are in the 30s. My apologies, I was not expecting to be called.

Question No. 34 relates to the issue of the service of insertion of pacemakers and defibrillators at Letterkenny General Hospital. This service has ceased since the end of last year. Initially, it was paused temporarily in order to contain costs but from the response I received from the HSE, the language sounds much more permanent than it did a few months ago. I want an explanation from the Minister and the HSE as to why this is happening. From my own assessment and investigation of the issue, it would appear that the cost of carrying out these services and treatments is more expensive at the hospitals where patients are now being treated, namely, Galway and St. James's. It costs more, in terms of ambulance services, to transport the patients - upwards of €1,000. It also costs in nurse accompaniment for patients, which I estimate at well over €200. Also, from my investigations of it, the length of stay involved at these hospitals is longer. What was being provided at Letterkenny was quite an efficient service. It was being done quickly because it was being done on site. There was an efficient team and staff in Letterkenny, and those staff are still in place. Instead, in order to achieve cost containment, those patients are being transported down the country to other hospitals. That funding, more that would have been coming out of Letterkenny, is coming out of the other hospitals' budgets. We are seeing an erosion of the cardiac services available to the north west through Letterkenny. Inevitably, the ability to attract quality cardiac staff to Letterkenny will be diminished because if staff who have the capacity to do this type of work are not able to do it on a day-to-day basis, they will become de-skilled and they certainly will not want to come to the area. Effectively, we are seeing the cardiac services of the hospital being diminished, and for something that logically and numerically does not make sense. I ask the HSE to examine that, explain its position and reverse this move by reinstating the service in Letterkenny General Hospital.

On the other key points, I raised the issue of community hospital beds. I welcome that in the case of Carndonagh, Buncrana and Ramelton nursing community hospitals the Minister states there will not be any reduction in the existing bed capacity. As the committee will be aware, there have been some beds lost in the past year or two, but it is crucial that this does not happen anymore. I welcome the commitment he is giving in that regard.

Question No. 36 relates to the impact of the HSE west service plan for Letterkenny General Hospital. The answer elicits the reality that the HSE is looking for an €11.6 million reduction in Letterkenny's budget from what would have been spent last year. Letterkenny has been operating as one of the more efficient hospitals in the country. It has a much higher service return for the input of costs. It does not make sense to enforce budget cuts on a hospital without taking into account in advance the impact assessment in treatments. As the Minister outlined at the outset, his intention is that money would follow the patient. We have an example of where this hospital is being efficient but we are not seeing the money follow it as such. I ask that attention be given to that and that the Minister ensures the budget is protected there because he is getting value for money out of it.

Chairman

I call the Minister and Mr. Magee.

Mr. Cathal Magee

We will start with the NCHDs, and Senator Colm Burke's questions, which will be taken by Mr. Barry O'Brien.

Mr. Barry O’Brien

On the questions raised by Deputy Naughten and Senator Colm Burke about the recruitment of NCHDs, 84% of all NCHD posts are the responsibility of postgraduate bodies. These are dedicated training posts for NCHDs. The remainder are service posts spread across the hospital system in both HSE and voluntary hospitals for which the HSE has responsibility for filling and recruiting.

As 98% of all NCHD posts are filled in the normal way, our reliance on agency staff is currently less than 2%. In a bid to reduce further our dependency, we launched a centralised application process in February. We wanted to move away from the focus on the intake dates in January and July by creating a database to which NCHDs could apply on a continual basis. Applications are passed on to hospitals which have vacant posts or require locum cover, thereby allowing us to respond in a more timely manner when NCHD vacancies arise. We are contacting 3,800 applicants to advise them of the process. Clinicians in local hospitals are still involved in the recruitment process.

Deputy Naughten asked about the grouping of hospitals. It falls to the CEO and clinical director of a hospital group to redeploy NCHDs to meet the service needs of individual hospitals.

Dr. Philip Crowley

In regard to Senator Colm Burke's welcome questions about graduate retention, this an issue of major concern in terms of quality and safety. In partnership with the forum of postgraduate training bodies, we sat down with a cross-section of NCHDs to build on the survey described in our written response to the Senator to better understand the startling statistic that 43% of the interns from the 2011 output have left the country. We do not have a series of actions to share with the committee today because the consultation had the outcome of raising a number of issues which are now being examined by a group, which includes NCHDs, with a view to converting them into actions. I will share these actions with the committee when they are decided. The main issues arising are predictable in that they concern supporting NCHDs while they work in this country, mentoring, better career structures and supports, ensuring NCHDs play an appropriate role without being asked to perform tasks that are not appropriate to their skill sets and access to the resources they require for training.

Ms Laverne McGuinness

Deputy Catherine Byrne asked about St. Brigid's nursing home in Crooksling and people being sent home from long-term care settings. We have trawled the system to find out about that issue and it is not happening as far as we are aware. If the Deputy wishes to bring individual cases to our attention we will be happy to take them on board. Our overall aim is to keep people at home for as long as possible through home help or home care services, followed by the alternative of transitional or intermediate care before we consider long-term care. We want to reduce the proportion of people going into long-term care from 4.5% to 4%.

The Deputy spoke about home help and people coming in to make a cup of tea or sweep the floor. Despite this year's reduction in home help hours, we have ensured that providers of home help services concentrate on personal care. That is the task they are trained to perform.

Chairman

Has the HSE communicated with the Carers Association on that issue?

Ms Laverne McGuinness

We have communicated with the parties concerned and have also released a report on the matter. Approximately 50,000 people benefit from the 10.7 million home help hours made available this year and we have not reduced our home care packages. Currently, 10,570 packages are in place and it is our intention to ensure as many people stay at home as possible.

The details of the consultation process on St. Brigid's and other proposals to close units will be available in the next two weeks. The process has not yet started but it will have to go to ministerial level before the decision can be made to close a unit. All measures have been taken to determine whether the unit can be put to other uses and a viability analysis is expected to be completed by the end of April.

Mr. Cathal Magee

In regard to primary care centres, there is no policy decision that people should not respond to public representatives. Perhaps we can follow up on Deputy Catherine Byrne's question when we get further details. We do not think it is appropriate.

I welcome the Deputy's comments on the two primary care centres. We face a challenge in Ballyfermot to ensure GPs move to the new centre. We are at present working through the issue, which is critical to an effective opening. We will reply directly to the Deputy's question on the future use of the centre.

Mr. Barry White

I am not aware of any clinical reason services cannot be provided in Letterkenny. It is purely a financial issue. I take the point about the costs associated with transfer across the system. We will investigate the issue.

Chairman

Can Dr. Crowley answer Senator Colm Burke's question about the Medical Council?

Dr. Philip Crowley

The Medical Council is an independent body but I liaise with it on behalf of the HSE. If the Senator gives me details of specific cases, I will seek clarification on the reason for the delay.

Senator Colm Burke

In one case an individual received the same e-mail in response to five separate inquiries. That is not good enough in this day and age, especially when it involves an Irish trained graduate who has worked in an Irish hospital.

Dr. Philip Crowley

The matter should be relatively straightforward. I will pursue it more clearly if I have the details.

Ms Laverne McGuinness

Deputy McConalogue asked about the budgetary issues arising in Letterkenny. At the end of 2011 Letterkenny came in with a significant deficit of more than €7 million and this has contributed to its financial challenges in 2012. It is not the case that it was totally top sliced, as it were. It is projected to run a deficit of €7 million again this year after putting in place a number of cost containment measures. I am working closely with the hospital and its clinicians and I have visited it twice in the past six weeks. It is a high performing hospital and has scored green on our HealthStat, which is our key performance dashboard. However, it has high levels of emergency department activity and it cannot get through its elective procedure workload. We have established a steering group to investigate how the new emergency department can be opened within current resources and to suggest ways of ring-fencing surgical beds to get through the elective procedures. Clinicians are involved in this group and it is led by surgery services. Over the next ten to 12 weeks the group will produce a piece of work that we will be able to forward to the Deputy in regard to what it will be able to achieve within its current budget. Further work will be required to find out how we can address its deficits. We investigated what financial assistance could be provided this year but it needs to corral its costs further. We are working with it on that.

Mr. Barry White

It is now in the prospective funding for orthopaedic surgery so elective hip and knee operations are being prospectively funded. In other words money is following the patient on that from, I believe, 1 April. It has already demonstrated fairly exceptional performance in that area.

Deputy James Reilly

I will be very brief because I need to leave at 2 o'clock and it is now 2 o'clock. Dr. Crowley has dealt with the medical council registration. We will bring it to its attention. I would be very grateful to have any of the details the Senator might have on that. We do not want to have any inefficiencies in the system that make life more difficult to retain professionals. On the career path issue, a study was completed by Mr. Ambrose McLoughlin at my request. It is now with the Department and needs to be shortened and sent out for further consultation. There has been consultation with NCHDs and there will be further consultation as pointed out by Dr. Crowley. We want to create a new clear career path of them. I previously mentioned the entry consultant grade, which will allow them to progress to full consultant later. I emphasise this every time I talk about it. This is not a graveyard for people who do not want to progress, but it is part of the natural progression.

I thank Deputy Byrne for her comments on the medical card improvement. A review of the fair deal scheme will be completed later this year. The terms of reference are to examine the ongoing sustainability of the scheme; the relative costs of public versus private provision; the effectiveness of current methods of negotiating price in private and setting price in public nursing homes; and the balance of funding between residential and community care. We are concerned that because that is where the large pot of money is, everybody tends to seek access to the fair deal scheme long before they should.

We need more balanced funding. In the coming weeks there will be an announcement by the clinical programmes on the new initiative for care for the elderly, which will allow for frail elderly units in our bigger hospitals where patients will be fully assessed and passed on to intermediate care centres where they can continue rehabilitation. Transitional facilities are available where patients are going to long-term care but have not yet been accepted under the fair deal scheme. They can reside there until their final destination is sorted out. Some people will go straight from their three weeks in an acute unit to long-term care, having had their rehabilitation and full assessment. However, many will go into intermediate care and most of those will go home. Ms McGuinness has made the point, which I would re-emphasise, that while there may have been a reduction in home help hours, there is no reduction in home care packages. Those are the important ones in keeping people out of hospital in terms of their personal care as they allow people to be bathed, showered, dressed in the morning, etc.

On the health centre in Ballyfermot, as Minister for Health I would not countenance allowing any directive to issue. We will investigate this and find out who is responsible and who said it to the Deputy. We will get to the root of that. It is not acceptable. Public representatives are entitled to make representations on behalf of their constituents. We will come back to the committee with a report on unit 3 in the HSE, which might be wiser. I know that there is an issue with GPs moving into the new Ballyfermot health-care centre. I will take full advantage of the new law that allows any GP who is suitably qualified to take on GMS patients to seek expressions of interest for new GPs to come into that Ballyfermot health centre if existing GPs do not wish to, which is as it should be.

In response to Deputy McConalogue, in talking about the cardiac issues which have been addressed, I point out that while there is a 9 a.m. to 5 p.m. service in Letterkenny, I would like to see a 24-hour centre for the north west. In that case and in the case of hospitals generally, we need to consider the opportunities presented by more co-operation between North and South in terms of services required and populations that need to be served. Certain services are short on both sides of the Border and we need to consider where they will be provided. It then becomes economically viable and safe to do it. We need to remember that where a service has inadequate throughput the individuals providing the service do not maintain their skill-set and standards fall. That is a problem for us, but it is something that we can address through further discussion with the Northern Ireland Minister of Health, Social Services and Public Safety, Mr. Poots, MLA, and the people in the North on the services we can provide. I met representatives of the Lifford hospital. I have asked them to talk to, and we will explore with, people in Strabane how we might make better use of that unit given the population it serves.

I have no more to add. I believe Deputy Fitzpatrick is the last member who wishes to speak.

Deputy Peter Fitzpatrick

People in Dundalk and the surrounding area are concerned about the Louth County Hospital laboratory service moving to Drogheda. Some 85% of the workload is GP-driven and 15% comes from clinical work. Is it the responsibility of the GP to get the blood specimens to Drogheda or to send them to the Louth County Hospital for it to have them couriered to Drogheda? Can people go directly to the Louth County Hospital and leave their specimens there? Are many GPs in Louth using the HealthLink IT system which is available in Drogheda? The Louth County Hospital is an excellent hospital and is open for business. I am glad to hear that the Minister will shortly publish a framework for the development of smaller hospitals. It is also good news that they will provide more services for more patients in the local communities. It is important that the Louth County Hospital in Dundalk remains open seven days per week and 12 hours per day.

Chairman

I will call Deputy Ó Caoláin followed by Deputy Naughten. I ask them to be brief so that we can allow the Minister to leave.

Deputy Caoimhghín Ó Caoláin

I have two questions for the CEO. The reply on the north east plan for the acute hospitals indicated that a further 100 beds would close, but with no indication as to where they might be. At the height of the Celtic tiger with the closure of a significant number of beds in Monaghan and the displacement of acute services to Cavan, no additionality was created either at Cavan or Drogheda hospital sites with the result that we are already working off a low base in the north east. How will we contend with a further 100-bed reduction across the acute hospital cohort in that region?

Regarding mental health services, prior to 29 February the PNA flagged that some 400 psychiatric nurses would be leaving. As it transpires the figures now provided in replies indicate that is now 450. There are real concerns over the provision of mental health services. Mr. Magee spoke earlier about recruitment being undertaken, including in the mental health services. Can he give us an assurance that we will see the recruitment of at least a similar number to the number who have departed in order to sustain what is already a very pressured area of health-care delivery, the mental health services?

Deputy Denis Naughten

I ask the HSE representatives to come back to us with the latest ambulance response time report, which is due at this stage. Regarding Mr. O'Brien's response on recruitment, I had understood that was the situation, but it is not the case in the west. The medical director is not responsible for the deployment of the NCHDs, who are being recruited individually by the hospitals. Why has that policy continued to be implemented? It may only be happening in the west but it should not be happening. Every other appointment takes place on a group basis but the NCHDs are still being appointed on a hospital basis, which is causing significant problems for smaller hospitals.

Mr. Cathal Magee

We circulated the bed closures report prior to the meeting. There has been an issue with properly calibrating the definition of a bed closure and trying to get a standardised reporting system which is similar for all hospitals. We have circulated to the committee a first report which outlines the current situation. The service plan for the north east includes the requirements to deal with the funding and resource issues. It is something we will have to keep under review. There are significant financial pressures in Cavan hospital which will put further pressure on resources and capacity.

After the first three months we will review our service plan and examine the financial pressures and opportunities to maintain and optimise the level of service provided. The work of clinical programmes is huge and crucial in the implementation of acute medicine and surgery. Those programmes are effective in driving increased throughput and efficiencies in order to optimise the level of activity, particularly for elective cases.

We set out a fairly comprehensive answer to the Deputy's question on mental health services. There is a real opportunity in the area of mental health this year to deploy substantial resources, comprising 414 posts, in a strategic way to deal with the priorities and gaps in child and adult mental health teams and to accelerate the migration to the Vision for Change agenda.

Significant numbers are leaving mental health services, many from traditional and institutional service environments. Support staff are also leaving. We have set out the disciplines for recruitment in mental health. There is a real opportunity to target key areas in child and adult services, disciplines and locations where there are acute needs. Sometimes the balance of requirements across the country does not result in an equitable distribution of mental health resources and is more about tradition in particular locations.

I am quite positive about the opportunity this year to shift and significantly improve services, and deal with some of the gaps that have emerged over the past three years. A very detailed action plan is being developed within the service. A lot of work has been done, given the knowledge that the money and resources will be available. We hope to finalise that with the Minister and Department over the coming weeks. It will represent a significant programme of work to stabilise the service, make sure key gaps are being filled and provide a development path for the implementation of the Vision for Change agenda. We will see a significant improvement in mental health services from a resource point of view this year.

Ms Laverne McGuinness

Mr. Magee has said everything. On specific replacements, there are 244 replacements for the 532 posts in the wider community services sector. Some involve mental health services, in particular consultant psychiatry, and some relate to mental health services in the Cavan-Monaghan area. I can give the Deputy exact details if he wishes rather than delay the meeting.

Deputy Caoimhghín Ó Caoláin

I thank Ms Laverne and Mr. Magee.

Ms Laverne McGuinness

There is no impact on the quality of laboratory services provided by virtue of their being moved. If the Deputy has specific questions about who can refer what or when, if he gives me his contact details, I will go through them.

Deputy Peter Fitzpatrick

What about the HealthLink IT system in Our Lady of Lourdes Hospital?

Ms Laverne McGuinness

We are working to put the HealthLink system in place and working.

Deputy Peter Fitzpatrick

Are any GPs in Louth currently using it?

Ms Laverne McGuinness

I am not sure. I will have to revert to the Deputy.

Mr. Barry O’Brien

I will deal specifically with Deputy Naughten on the individual hospital concerned and give him a comprehensive reply.

Deputy James Reilly

I thank the Chairman and Deputies for their questions. I thank the HSE and Department for their co-operation and for coming before the committee. It is important that we thank all the staff working in health services for embracing change and meeting the challenges the reduced budget, the moratorium and the retirement grace period presented. They continue to deliver care and services and maintain improvements in the numbers waiting on trolleys in departments. As I said at the outset, too many people are waiting on trolleys and more changes are to come. I will continue to challenge the system to treat more patients more quickly. I expect to be challenged to continue to deliver change for the better. I thank everyone for their input and look forward to seeing them again in the next quarter.

Chairman

I thank the Minister, Mr. Ray Mitchell of the parliamentary affairs division of the HSE for assisting in organising today's meeting, Mr. Paul Howard and the members of the HSE. I hope we will be able to send information to members faster before the next meeting because some only received information this morning or late last night.

Mr. Luke Woods is in the Gallery. He is the grandson of a former Minister, Mr. Michael Woods, and the son of Mr. Liam Woods. He is very welcome and I thank him for being here today. We wish his grandfather a very happy retirement.

The joint committee adjourned at 2.15 p.m. until 11.30 a.m. on Thursday, 29 March 2012.